Unesco International Guidelines on Sexuality Education 183281e

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International Guidelines

on Sexuality Education:

An evidence informed approach to effective sex,

relationships and HIV/STI education

Draft


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June 2009

Draft

International Guidelines

on Sexuality Education:An evidence informed approach to effective sex,

relationships and HIV/STI education


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The designations employed and the presentation of materials throughout this document do not

imply the expression of any opinion whatsoever on the part of UNESCO concerning the legal status

of any country, territory, city or area or its authorities, or concerning its frontiers and boundaries.

Published by UNESCO

UNESCO 2009

Education Sector

Division for the Coordination of UN Priorities in Education

Section on HIV and AIDS

7, place de Fontenoy

75352 Paris 07 SP, France

Website: www.unesco.org/aids

Email: [email protected]

Composed and printed by UNESCO

ED-2006/WS/36 REV (CLD 3049.9)


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Acknowledgements

These International Guidelines on Sexuality Education

were commissioned by Chris Castle and Ekua

Yankah in the Section on HIV and AIDS, Division for

the Coordination of United Nations (UN) Priorities inEducation at the United Nations Educational, Scientic

and Cultural Organization (UNESCO).

This document was written by Nanette Ecker, Director

of International Education and Training at the Sexuality

Information and Education Council of the United States

(SIECUS) and by Douglas Kirby, Senior Scientist at

ETR (Education, Training, Research) Associates.

Peter Gordon, independent consultant, edited various

drafts.

UNESCO would like to thank the William and Flora

Hewlett Foundation for hosting the global technical

consultation that contributed to the development of the

guidelines. The organizers would also like to express

their gratitude to all of those who participated in the

consultation, which took place from 18-19 February

2009 in Menlo Park, USA (in alphabetical order):

Arvin Bhana, Human Sciences Research Council

South Africa; Chris Castle, UNESCO; Dhianaraj Chetty,

ActionAid; Esther Corona, Mexican Association for Sex

Education and World Association for Sexual Health;Mary Guinn Delaney, UNESCO; Nanette Ecker, SIECUS;

Nike Esiet, Action Health, Inc. (AHI); Peter Gordon,

independent consultant; Christopher Graham, Ministry

of Education, Jamaica; Nicole Haberland, Population

Council/USA; Douglas Kirby, ETR Associates; Sam

Kalibala, Population Council/Kenya; Wenli Liu, Beijing

Normal University; Elliot Marseille, Health Strategies

International; Helen Omondi Mondoh, Egerton

University; Prabha Nagaraja, Talking about Reproductive

and Sexual Health Issues (TARSHI); Hans Olsson, The

Swedish Association for Sexuality Education; Grace

Osakue, Girls Power Initiative (GPI) Edo State, Nigeria;

Jo Reinders, World Population Fund (WPF); Sara

Seims, the William and Flora Hewlett Foundation; Ekua

Yankah, UNESCO

Written comments and contributions were also gratefully

received from (in alphabetical order):

Vicky Anning, independent consultant; Andrew Ball,

World Health Organization (WHO); Tanya Baker, Youth

Coalition for Sexual and Reproductive Rights; Jeffrey

Buchanan, UNESCO; Chris Castle, UNESCO; Katie

Chau, Youth Coalition for Sexual and Reproductive

Rights; Judith Cornell, UNESCO; Anton De Grauwe,

UNESCO International Institute for Educational Planning

(IIEP); Jan De Lind Van Wijngaarden, UNESCO; Marta

Encinas-Martin, UNESCO; Jane Ferguson, WHO;

Dakmara Georgescu, UNESCO International Bureau of

Education (IBE); Anna Maria Hoffmann, United Nations

Childrens Fund (UNICEF); Roger Ingham, University of

Southampton; Changu Mannathoko, UNICEF; Rafael

Mazin, Pan-American Health Organization (PAHO);

Maria Eugenia Miranda, Youth Coalition for Sexual and

Reproductive Rights; Jenny Renju, Liverpool School

of Tropical Medicine & National Institute for Medical

Research, United Republic of Tanzania; Mark Richmond,

UNESCO; Justine Sass, UNESCO; Barbara Tournier,

UNESCO IIEP; Friedl Van den Bossche, UNESCO;Diane Widdus, UNICEF; Arne Willems, UNESCO; Ekua

Yankah, UNESCO.

UNESCO would like to acknowledge Sandrine Bonnet,

UNESCO IBE; Claire Cazeneuve, UNESCO IBE; Claire

Gresl-Favier, WHO; Magali Moreira, UNESCO IBE and

Lynne Sergeant, UNESCO IIEP for their contributions

to the bibliography of useful resources.


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AcronymsASRH Adolescent sexual and reproductive health

AIDS AcquiredImmuneDeciencySyndrome

ART Anti-retroviral Therapy

CEDAW Convention on the Elimination of All Forms of Discrimination against WomenCRC Convention on the Rights of the Child

EFA Education for All

ETR Education, Training and Research

FHI Family Health International

HFLE Health and Family Life Education

HIV HumanImmunodeciencyVirus

HPV Human Papilloma Virus

IATT Inter-Agency Task Team

IBE International Bureau of Education (UNESCO)

ICPD International Conference on Population and Development

IIEP International Institute for Educational Planning (UNESCO)

IPPF International Planned Parenthood Federation

LGBTQ Lesbian, Gay, Bisexual, Transgender, Questioning

MDG Millennium Development Goal

MoE Ministry of Education

MoH Ministry of Health

NGO Non-Governmental Organization

PEP Post-exposure prophylaxis

SIECUS Sexuality Information and Education Council of the United States

SRE Sex and relationships education

SRH Sexual and reproductive health

SRHR Sexual and reproductive health and rights

STD Sexually transmitted disease

STI Sexually transmitted infection

UN United Nations

UNAIDS Joint United Nations Programme on HIV/AIDS

UNESCO UnitedNationsEducational,ScienticandCulturalOrganization

UNFPA United Nations Population Fund

UNICEF United Nations Childrens Fund

VCT Voluntary Counselling and Testing

WHO World Health Organization


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Table of Contents

Acknowledgements iii

Acronyms iv

Part I: The rationale for sexuality education 1

1. Introduction 2

2. Background 5

3. Building support for sexuality education 84. The evidence base for sexuality education 12

5. Characteristics of effective programmes 17

Part II: Topics and learning objectives 25

1. Age range 26

2. Components of learning 27

3. Points of entry 27

4. Structure 285. Presentation 29

6. Overview of key concepts and topics 29

Tables of learning objectives 30

Endnotes 57

Part III: Appendices 59

I. Glossary on sex and sexuality terms 60

II. International conventions outlining the entitlement to sexuality education 63

III. Interview schedule and methodology 65

IV. Criteria for selection of evaluation studies and review methods 57

V. People contacted and key informant details 68

VI. Bibliography of useful resources 70

VII. List of participants from the UNESCO global technical consultation

on sexuality education 77

VIII. Reference material for the International Guidelines 79


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Part 1:The rationale forsexuality education


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1. Introduction

1.1 What is sexuality educationand why is it important?

This document is based upon the following assumptions:

Sexuality is a fundamental aspect of human life: it has

physical, psychological, spiritual, social, economic,

political and cultural dimensions.

Sexuality cannot be understood without reference to

gender.

Diversity is a fundamental characteristic of sexuality.

The rules that govern sexual behaviour differ widely

across and within cultures. Certain behaviours are seen

as acceptable and desirable while others are considered

unacceptable. This does not mean that these behaviours

do not occur, or that they should be excluded from

discussion within the context of sexuality education.

Few young people receive adequate preparation for their

sexual lives. This leaves them potentially vulnerable to

coercion, abuse and exploitation, unintended pregnancyand sexually transmitted infections (STIs), including HIV.

Many young people approach adulthood faced with

conicting and confusing messages about sexuality and

gender. This is often exacerbated by embarrassment,

silence, and disapproval of open discussion of sexual

matters by adults, including parents and teachers, at the

very time when it is most needed. Globally, young people

are becoming sexually mature and active at an earlier

age. They are also marrying later, thereby extending the

period of time from sexual debut until marriage.

It is therefore essential to recognise the need and

entitlement ofallyoung people to sexuality education.

Some young people are more vulnerable than others,

particularly those with disabilities and those living with

HIV.

Effective sexuality education can provide young

people with age-appropriate, culturally relevant and

scientically accurate information. It includes structured

opportunities for young people to explore their attitudes

and values, and to practise the skills they will need to

be able to make informed decisions about their sexual

lives.

Effective sexuality education is a critical part of HIV

prevention and is also critical to achieving Universal

Access1 targets for prevention, treatment, care and

support. While there are no programmes that can

eliminate the risk of HIV and other STIs, unintended

pregnancy, and coercive or abusive sexual activity,

properly designed and implemented programmescanreduce some of these risks.

Studies show (see section 4) that effective programmes

can:

reduce misinformation;

increase knowledge;

clarify and solidify positive values and attitudes;

increase skills; improve perceptions about peer group norms; and

increase communication with parents or other

trusted adults.

Research shows that programmes sharing certain key

characteristics can help to:

delay the debut of sexual intercourse;

reduce the frequency of unprotected sexual

activity;

reduce the number of sexual partners; and

increase the use of protection against pregnancy

and STIs during sexual intercourse.

School settings provide an important opportunity to

reach large numbers of young people with sexuality

education before they become sexually active, as well

as offering an appropriate structure (i.e. the formal

curriculum) within which to do so.


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1.2 What are the goalsof sexuality education?

The primary goal of sexuality education is that children and

young people are equipped with the knowledge, skills and

values to make responsible choices about their sexual andsocial relationships in a world affected by HIV and AIDS.

Sexuality education programmes usually have several

mutually reinforcing objectives:

to increase knowledge and understanding;

to explain and clarify feelings, values and attitudes;

to develop or strengthen skills; and

to promote and sustain risk-reducing behaviour.

In a context where ignorance and misinformation can

be life-threatening, sexuality education is part of the

duty of care of education and health authorities and

institutions. In its simplest interpretation, teachers in the

classroom have a responsibility to act in the place of

parents, contributing towards ensuring the protection

and well-being of children and young people. At another

level, the International Guidelines call for political and

social leadership from education and health authorities

to respond to the challenge of giving children and young

people access to the knowledge and skills they need in

their personal, social and sexual lives.

When it comes to sexuality education, programme

designers, researchers and practitioners sometimes

differ in the relative importance they attach to each

objective and to the overall intended goal and focus.

For educationalists, sexuality education is a broader

activity in which increasing knowledge (e.g. about HIV)

is valued both as a worthwhile outcome in its own

right, as well as being a rst step towards adopting

safer behaviour. For public health professionals, the

conceptual emphasis would be on reducing sexual risk

behaviour. In these International Guidelines, sexuality

education combines a rights-based approach with the

best available evidence and encompasses a broad

range of topics and concepts that may or may not

include behaviourally dened outcomes.

Different kinds of evidence exist in relation to sexuality

education: practitioner experience and expert opinion, for

example, about promising approaches; as well as the

conventional standards of published research studies.

While section four on the evidence base of sexuality

education is drawn primarily from published research

studies, the International Guidelines are also deliberatelyinformed by practitioner experience and expert opinion.

1.3 What are the purpose andintended audience of the

International Guidelines?

These International Guidelines have been developedprimarily to assist education, health and other relevant

authorities in the development and implementation of

school-based sexuality education programmes and

materials. It does this primarily by recommending a

set of age-specic standard learning objectives for

sexuality education.

The International Guidelines will have immediate

relevance for education ministers and their professional

staff, including curriculum developers, school principals

and teachers. However, anyone involved in the design,

delivery and evaluation of sexuality education, in and

out of school, may nd this document useful. Emphasis

is placed on the need for programmes that are logically

designed, that address factors such as beliefs, values

and skills that are amenable to change and which, in

turn, may affect sexual behaviour.

The International Guidelines are a framework for

offering guided access to information and knowledge

to children and young people about sex, relationships

and HIV/STIs within a structured teaching/learning

process. They are intended to:

Promote an understanding of the need for sexuality

education programmes by raising awareness of

salient sexual and reproductive health issues and

concerns affecting children and young people;

Provide a clear understanding of what sexuality

education comprises, what it is intended to do, and

what the possible outcomes are;

Provide guidance to education authorities on how

to build support at community and school level for

sexuality education;

Build teacher preparedness and enhance

institutional capacity to provide good quality

sexuality education; and

Provide guidance on how to develop responsive,

culturally-relevant and age-appropriate sexuality

education materials and programmes.


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This document is not a curriculum. Instead, it focuses

on the why and what issues that require attention in

strategies to introduce or strengthen sexuality education.

The how to issues are dealt with in classroom

resources, curricula and materials for training teachers

that already exist. A list of recommended resources

can be found in Appendix VI.

The International Guidelines are based upon approaches

to sexuality education that are rights-based, culturally

sensitive, respectful of sexual and gender diversity,

comprehensive, scientically accurate, age-appropriate

and evidence-based. They are intended to address

the diverse realities and needs of young peoples lives

across a wide range of settings. The International

Guidelines are thus intended to be a global template,

on the basis of which regional and country adaptations

can be made in order to increase local relevance and

acceptance.

In a broader context, sexuality education is an essential

part of a good curriculum and, it could also be argued,

it is an essential part of a comprehensive response to

HIV and AIDS at the national level.

1.4 How are the InternationalGuidelines

structured?The International Guidelines are divided into three

parts. The rst part explains what sexuality education

is and why it is important. It sets out a clear overview

of the available evidence in relation to the impact of

sexuality education and presents the key characteristics

of effective programmes. The second part of the

International Guidelines presents a global template

of key concepts and topics, together with learning

objectives for four distinct age groups. They establish

a set of benchmarks with which to monitor the content

of what is being taught and to assess progress

towards the achievement of teaching and learning

objectives. The third section provides the reader with

detailed background information on the evidence base

described in Part I, together with other relevant and

practical resource material.

Thus, the International Guidelines provide a platform for

those involved in policy, advocacy and the development

of new programmes or the review and scaling up of

existing programmes.

1.5 How were the InternationalGuidelinesdeveloped?

The development of therationale was informed by

a specially commissioned systematic review of theliterature on the impact of sexuality education on sexual

behaviour. The review considered 87 studies from

around the world; 29 studies were from developing

countries, 47 from the United States and 11 from

other developed countries. Furthermore, common

characteristics of existing and evaluated sexuality

education programmes were outlined that have been

found to be effective in terms of increasing knowledge,

clarifying values and attitudes, increasing skills and at

times impacting upon behaviour. These characteristics

were identied and veried through independent

review.

The development of the topics and learning objectives

was informed by a specially commissioned review of

existing curricula, guidelines and standards as identied

by key informants and through searches of relevant

databases, websites and list serves2 (see Appendix V).

The review yielded a diverse sample of widely used, and

in some cases rigorously evaluated, sexuality education

curricula across a range of settings and audiences,

both in-school and out of school. Thus, while by no

means exhaustive, the topics and learning objectiveswithin these International Guidelines are drawn from a

wide range of resources.

Curricula from 12 countries3 were examined in order to

identify common topics and related learning objectives.

In addition, the Guidelines for Comprehensive Sexuality

Education, developed by the Sexuality Information and

Education Council of the United States (SIECUS), an

international non-governmental organization (NGO),

which draws on experience from India, Jamaica, Nigeria

and the United States were consulted. The SIECUS

Guidelines provide the overall organizing framework for

the topics and learning objectives.

The topics and learning objectives in these International

Guidelines have been selected on the basis of their

inclusion within positively evaluated curricula, as well

as relying on professional guidance from experts in

the eld. Thus, while the International Guidelines draw

from educational and behaviour change theory, they


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are solidly embedded in practical experience. Future

versions of the International Guidelines will be produced

and will incorporate feedback from their users around

the world, and will continue to be based on the best

available evidence.

These International Guidelines on sexuality educationwere further developed through key informant interviewswith recognised experts (see list in Appendix V), and

through a global technical consultation meeting held in

February 2009with experts from 13 different countries.

Colleagues from UNESCO, UNICEF and WHO have

also provided input for this document.

Decision-makers concerned with setting policy in

education and other institutions providing for young

people will be sensitive to the legal standing of these

International Guidelines in the international community.

In terms of process, they were developed by

contracting and consulting with leading experts in the

eld of sexuality education and with the support and

engagement of other UNAIDS Cosponsors. This is a

recognised and legitimate protocol which ensures the

highest quality safeguards, acceptability and ownership

at international level. At the same time, it should be

noted that the International Guidelines are voluntary

and non-binding in character and do not have the

force of an international normative instrument. Even for

an average school setting this is important; teachers

and school managers are called upon to balance therights of parents and the rights of children and young

people in areas of the curriculum which parents and

communities consider to be sensitive. It is hoped that

these International Guidelines constructively contribute

to this effort.

2. Background

2.1 Young peoples sexual andreproductive health

Sexual and reproductive ill-health are among the most

important contributors to the burden of disease among

young people. Ensuring the sexual and reproductive

health of young people makes social and economic

sense: HIV infection, other STIs, (unsafe) abortion and

unintended pregnancy all place substantial burdens on

families and communities and upon scarce government

resources and yet such burdens are preventable

and reducible. Promoting young peoples sexual and

reproductive health, including the provision of sexuality

education in schools, is thus a key strategy towards

achieving the Millennium Development Goals (MDGs),

especially MDG 3 (achieving gender parity), MDG 5

(reducing maternal mortality) and MDG 6 (combating

HIV and AIDS).

The sexual development of a person is a process that

comprises physical, psychological, emotional, social

and cultural dimensions. It is also inextricably linked tothe development of ones gender identity and it unfolds

within specic socio-economic and cultural contexts.

The transmission of cultural values from one generation

to the next forms a critical part of socialisation; it

includes values related to gender and sexuality. In many

communities, young people are exposed to several

sources of information and values (e.g. from parents,

teachers, media and peers). These often present them

with alternative or even conicting values about gender

and sexuality. Furthermore, parents are often reluctant

to engage in discussion of sexual matters with children

because of cultural norms, their own ignorance or

discomfort.

According to the World Health Organization (WHO,

2002), in many cultures puberty represents a time

of social as well as physical change for both boys

and girls. For boys, puberty can be a gateway to

increased freedom, mobility and social opportunities.

For girls, puberty may signal an end to schooling and

mobility, and the beginning of adult life, with marriage

and childbearing as expected possibilities in the near

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Being sexual is an important part of many peoples lives:

it can be a source of pleasure and comfort and a way

of expressing affection and love. Whether or not young

people choose to be sexually active, comprehensive

sexuality education prioritises the acquisition and/or

reinforcement of values such as reciprocity, equality

and respect that are prerequisites for healthier andsafer sexual and social relationships. Abstinence is only

one of a range of choices available to young people

and programmatic interventions need to be assessed

carefully in relation to the evidence base for sexuality

education.

The past four decades have seen dramatic changes

in our understanding of human sexuality and sexual

behaviour4. The global HIV epidemic has played a

role in bringing about this change, because it was

rapidly understood that, in order to address HIV

which is largely sexually transmitted we needed to

acquire a better understanding of gender and sexuality.

According to the Joint United Nations Programme on

HIV/AIDS (UNAIDS, 2008), more than ten million young

people globally are living with HIV, two-thirds of whom

live in sub-Saharan Africa. New HIV infections are

concentrated among young people, with roughly 45 per

cent of all new infections occurring among those aged

15 to 24 years. Globally, women constitute 50 per cent

of the total number of people living with HIV, but in sub-

Saharan Africa, this proportion rises to approximately

61 per cent5.

Box 1. Involving Young People

A report published in 2007 by the UK Youth Parliament, based

on questionnaire responses from over 20,000 young people,

says that 40 per cent of young people described the Sex and

Relationships Education (SRE) they had received as either

poor or very poor with a further 33 per cent describing it as

onlyaverage.Otherkeyndingsfromthesurveywerethat:

43 per cent of respondents reported not having been

taught anything about relationships;

55 per cent of the 12-15 year olds and 57 per cent of the

16-17 year old females reported not having been taught

how to use a condom;

Just over half of respondents had not been told where

their local sexual health service was located.

Involving a structure like the Youth Parliament in the process of

reviewing SRE provision yielded important data. The data also

shows the scale of the challenge in meeting young peoples

needs, even in developed countries education systems.

Source: Fisher, J. and McTaggart J. Review of Sex and

Relationships Education (SRE) in Schools, Issues 2008,Chapter 3, Section 14. www.teachernet.gov.uk/_doc/13030/

SRE%20nal.pdf or http://ukyouthparliament.org.uk/sre

In many countries, young people with HIV are living

longer, thanks to improved access to treatment with

anti-retroviral therapy (ART) and related medical and

psychosocial support. Young people living with HIV

have particular needs in relation to their sexual and

reproductive health, including: opportunities to discuss

living positively with HIV; sexuality and relationships; andissues relating to disclosure, stigma and discrimination.

However, these needs are often unmet. For example,

experience in Uganda6 reveals that young people living

with HIV are often discriminated against by sexual

and reproductive health services and are actively

discouraged from becoming sexually active. Sixty per

cent of those living with HIV reported that they had not

disclosed their status to their sexual partners; 39 per

cent were in relationships with a sexual partner who did

not have HIV. Many did not know how to disclose their

status to their partners.

Knowledge about HIV transmission remains low in many

countries, with women generally less well informed than

men. According to UNAIDS (2006), many young people

still lack accurate, complete information on how to

avoid exposure to HIV. While UNAIDS reports that more

than 70 per cent of young men know that condoms can

protect against HIV, only 55 per cent of young women

cite condoms as an effective strategy for HIV prevention.

Survey data from sixty-four countries indicate that only

40 per cent of males and 38 per cent of females aged

15 to 24 had accurate and comprehensive knowledgeabout HIV and its prevention7. UNAIDS (2007) reported

that at least half of students around the world did not

receive any school-based HIV education. Furthermore,

ve of fteen countries reporting to UNAIDS in 2006

indicated the coverage of HIV prevention in schools was

less that 15 per cent. This gure falls well short of the

global goal of ensuring comprehensive HIV knowledge

in 95 per cent of young people by 2010 (UN, 2001).

Globally, young people continue to have high rates of

STIs. According to the International Planned Parenthood

Federation (IPPF, 2006), each year at least 111 million

new cases of curable STIs occur among young people

aged between 10 and 24, and up to 4.4 million girls

aged 15 to 19 years seek abortions, the majority of

which will be unsafe. Ten per cent of births worldwide

are to teenage mothers, who experience higher rates of

maternal mortality than older women.
http://www.teachernet.gov.uk/_doc/13030/SRE%20final.pdfhttp://www.teachernet.gov.uk/_doc/13030/SRE%20final.pdfhttp://www.teachernet.gov.uk/_doc/13030/SRE%20final.pdfhttp://ukyouthparliament.org.uk/srehttp://ukyouthparliament.org.uk/srehttp://www.teachernet.gov.uk/_doc/13030/SRE%20final.pdfhttp://www.teachernet.gov.uk/_doc/13030/SRE%20final.pdf


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2.2 The role of schools

In the larger context, the education sector has a critical

role to play in preparing children and young people for

their adult roles and responsibilities8

. The transitionto adulthood requires being informed and equipped

with the appropriate skills and knowledge to make

responsible choices in our social and sexual lives. In

most countries, young people between the ages of

ve and thirteen spend relatively large amounts of time

in school. Thus, schools provide a practical means of

reaching large numbers of young people from diverse

social backgrounds in ways that are replicable and

sustainable9. Teachers are likely to be the most skilled

and trusted source of information. Evidence from

UNESCO, WHO, the UNICEF and the World Bank

point to a core set of cost-effective activities that can

contribute to making schools healthy for children10.

Moreover, in many countries, young people have their

rst sexual experiences while they are still attending

school, making the setting even more important as

an opportunity to provide education about sexual and

reproductive health. In many communities, schools are

also social support centres, trusted institutions that can

link children, parents, families and communities with

other services (for example, health services). Thus, they

have the potential to promote communication aboutimportant issues between young people, trusted adults

and the broader community.

2.3 Young peoples needsand entitlement to

sexuality education

Young people want and need sexual and reproductive

health information (Biddlecom, 2007). Some organizations

now promote sexual and reproductive health education

as a right and argue that this is supported by specic

conventions (see Appendix II). For example, the Center

for Reproductive Rights (2008) argues that international

human rights standards, as articulated by UN governing

bodies and other international organizations, require

that governments guarantee the rights of young people

to health, life, education and non-discrimination, by

making comprehensive sexuality education that is

scientically accurate, objective and free from prejudice

and discrimination available to them in primary and

secondary schools.

In these International Guidelines the need for sexualityeducation is interpreted from the standpoint that

children and young people have a specic need for

information and skills on sexuality education that makes

a difference to their life chances. The threat to life and

their well-being exists in a range of contexts, whether it

is in the form of abusive relationships, exposure to HIV

or stigma and discrimination because of their sexual

orientation. Given the complexity of the task facing

any teacher or parent in guiding and supporting the

process of learning and growth, it is crucial to strike the

right balance between the need to know and what is

age appropriate and relevant.

2.4 Addressing sensitiveissues

The challenge for sexuality education is to reach young

people before they become sexually active, whether

this is through choice, necessity (e.g. in exchange for

money, food or shelter) or coercion. Some students,now or in the future, will be sexually active with members

of their own sex. These are sensitive and challenging

issues for those with responsibility for designing and

delivering sexuality education. Overlooking same-sex

relationships is not a solution.

Furthermore, in countries with low HIV prevalence, the

needs of those who may be most vulnerable must be taken

into consideration in sexuality education programmes.

For many developing countries, this discussion will require

attention to other aspects of vulnerability, particularly

poverty, disability and socio-economic factors.

These International Guidelines emphasise the

importance of addressing therealityof young peoples

sexual lives: this includes those aspects of which

policy-makers and others may personally disapprove.

Decision-makers with a duty of care have to recognise

that good scientic evidence and public health

imperatives should take priority over personal opinion.


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3. Building support for sexuality educationDespite the clear and pressing need for effective school-based sexuality education, in most countries throughout

the world this is still not available. There are many reasons for this, including perceived or anticipated resistance

resulting from misunderstandings about the nature, purpose and effects of sexuality education. Evidence suggeststhat many people, including education ministry staff, school principals and teachers, may not be convinced of the

need to provide sexuality education, or else are reluctant to provide it because they lack the condence and skills

to do so. Teachers personal or professional values could also be in conict with the issues they are being asked

to address, or else there is no clear guidance about what to teach and how to teach it (see Table 1, which provides

some typical examples of concerns that are expressed about introducing or promoting sexuality education).

Table 1. Common concerns about the provision of sexuality education

Concerns Response

Sexuality education leads to

early sex.

Research from around the world clearly indicates that, rather than leading to early sexual initiation,

sexuality education leads to later and more responsible sexual behaviour.

Sexuality education depriveschildren of their innocence.

Gettingtherightinformationthatisscienticallyaccurate,non-judgemental,age-appropriateandcomplete,at an early age, is something to which all children and young people are entitled. In the absence of this,

childrenandyoungpeoplewilloftenreceiveconictingandsometimesdamagingmessagesfromtheir

peers, the media or other sources. Good quality sexuality education balances this through the provision of

correct information and an emphasis on values.

Sexuality education is

against our culture or

religion.

The International Guidelines are built upon the principle of being culturally relevant as well as engaging

and building support among the custodians of culture in a given community. Key stakeholders, including

religious leaders, must be involved in the development of what form sexuality education takes. At the

same time, respect for culture and values has to be balanced with the needs of young people, especially

girls and young women.

It is the role of parents

and the extended family to

educate our young people

about sexuality.

Traditional mechanisms for preparing young people for sexual life and relationships may be breaking

down in some places, often with nothing left in their place. Sexuality education recognises the primary

role of parents and the family as a source of information, support and care in shaping a healthy approach

to sexuality and relationships. Governments role, through ministries of education, schools and teachers,

is to provide a safe and supportive learning environment and the tools and materials for good quality

sexuality education.

Parents will object to

sexuality education being

taught in schools.

Schools and education institutions where children and young people spend a large part of their lives are

an appropriate environment for young people to learn about sex, relationships and HIV/STIs. When these

institutions function well, young people are able to develop the values, skills and knowledge to make

informed and responsible choices in their social and sexual lives. Furthermore, teachers remain the best

qualiedandthemosttrustedprovidersofinformationandsupportformostchildrenandyoungpeople.

Sexuality education may be

good for young people, but

not for young children.

These International Guidelines are built upon the principle of age-appropriateness reected in the

grouping of learning objectives. Sexualityeducation encompasses a rangeof relationships, notonly

sexual relationships. Children are aware of and recognise these relationships long before they act on

their sexuality and therefore need the skills to understand their bodies, relationships and feelings from

an early age. Sexuality education lays the foundations e.g. learning correct names for parts of the body,

understanding principles of human reproduction, exploring family and interpersonal relationships and

learningconceptssuchassafetyandcondence.Thesecanthenbebuiltupongradually,inlinewiththe

age and development of a child.

Teachers may be willing to

teach sexuality education

but are uncomfortable,

lacking in skill or afraid to

do so.

Well-trained, supported and motivated teachers are an essential part of the delivery of good quality

sexuality education. Clear sectoral and school policies and curricula help to support teachers in the

delivery of sexuality education in the classroom. Teachers should be encouraged to specialise in sexuality

education throughaddedemphasisonformalisingthesubject inthecurriculum,aswellas stronger

professional development and support.

Sexuality education is

already covered in other

subjects (biology, life skills

or civics education).

Ministries, schools and teachers in many countries are already responding to the challenge of improving

sexuality education. Whilst recognising the value of these efforts, using these International Guidelines

presents an opportunity to evaluate and strengthen the curriculum, teaching practice and the evidence

baseinadynamicandrapidlychangingeld.

Sexuality education shouldpromote values.

These International Guidelines on sexuality education support a rights-based approach in which valuesare inextricably linked to universally accepted human rights.


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Facilitating dialogue between different stakeholders,

especially between young people and adults, could be

considered as one of the strategies to build support. In

many cases, especially around such sensitive issues,

the voices of young people are rarely heard and

understood.

3.1 Key stakeholders

Opposition to sexuality education is not inevitable.

Should opposition occur, it is by no means

insurmountable. Ministries of education have to play

a critical role in building consensus on the need for

sexuality education through consultation and advocacy

with key stakeholders, including, for example:

Young people and organizations that work with

them (including youth parliaments);

Policy-makers and politicians;

Government ministries, including health and others

concerned with the needs of young people;

Education professionals and institutions including

teachers, head teachers and training institutions;

Teachers trade unions;

Parent-teacher associations;

Religious leaders and/or faith-based organizations;

Researchers; Local communities and their representatives;

Lesbian, gay, bisexual and transgender groups;

NGOs, particularly those working on sexual and

reproductive health with young people;

Media (local and national);

Training institutions for health professions; and

Donors.

Young people need to be involved in the development

and design of programmes to ensure that these are

youth-friendly, gender-sensitive, rights-based, and that

they reect the reality of their lives. Sexuality education

is important for all children and young people, in and

out of school. While these International Guidelines

focus specically upon the school setting, much of the

content will be equally relevant to those children who

are out of school.

3.2 Developing the case forsexuality education

A clear rationale for the introduction of sexuality

education can be developed on the basis ofevidence from the local/national situation and needs

assessments. This should include local data on HIV,

other STIs and teenage pregnancy, sexual behaviour

patterns of young people, including those thought to

be most vulnerable, together with studies on specic

factors associated with HIV/STI risk and vulnerability.

Ideally, this will include both quantitative and qualitative,

sex and gender-specic data regarding the age of

sexual initiation, partnership dynamics including the

number of sexual partners, age differences, coercion,

duration and concurrency, as well as use of condoms

and contraception.

Box 2. Latin America:

Leading the call to action

A growing number of governments around the world are

conrming their commitment to sexuality education as a

priority essential to achieving national development, health

and education goals. In August 2008, health and education

ministers from across Latin America and the Caribbean came

togetherinMexicoCitytosignahistoricdeclarationafrming

a mandate for national school-based sexuality and HIV

education throughout the region. The declaration advocates for

strengthening comprehensive sexuality education and to make

it a core area of instruction at both primary and secondary

schools in the region.

Main features of the Ministerial Declaration:

Implement and/or strengthen multisectoral strategies of

comprehensive sexuality education and promotion and

care of sexual health, including HIV prevention;

Comprehensive sexuality education entails human rights,

ethical, biological, emotional, social, cultural and gender

aspects; respects diversity of sexual orientations and

identities.

See also: http://www.unaids.org/en/KnowledgeCentre/

Resources/FeatureStories/archive/2008/20080731_Leaders_

Ministerial.asp

http://data.unaids.org/pub/BaseDocument/2008/20080801_

minsterdeclaration_en.pdf

http://data.unaids.org/pub/BaseDocument/2008/20080801_

minsterdeclaration_es.pdf
http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2008/20080731_Leaders_Ministerial.asphttp://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2008/20080731_Leaders_Ministerial.asphttp://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2008/20080731_Leaders_Ministerial.asphttp://data.unaids.org/pub/BaseDocument/2008/20080801_minsterdeclaration_en.pdfhttp://data.unaids.org/pub/BaseDocument/2008/20080801_minsterdeclaration_en.pdfhttp://data.unaids.org/pub/BaseDocument/2008/20080801_minsterdeclaration_es.pdfhttp://data.unaids.org/pub/BaseDocument/2008/20080801_minsterdeclaration_es.pdfhttp://data.unaids.org/pub/BaseDocument/2008/20080801_minsterdeclaration_es.pdfhttp://data.unaids.org/pub/BaseDocument/2008/20080801_minsterdeclaration_es.pdfhttp://data.unaids.org/pub/BaseDocument/2008/20080801_minsterdeclaration_en.pdfhttp://data.unaids.org/pub/BaseDocument/2008/20080801_minsterdeclaration_en.pdfhttp://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2008/20080731_Leaders_Ministerial.asphttp://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2008/20080731_Leaders_Ministerial.asphttp://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2008/20080731_Leaders_Ministerial.asp


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3.3 Planning forimplementation

In some countries, National Advisory Councils

and/or Task Force Committees have been establishedby ministries of education to inform the development of

relevant policies, to generate support for programmes,

and to assist in the development and implementation

of sexuality education programmes. Council and

committee members have included young people,

national experts and practitioners in sexual and

reproductive health, rights, education, gender, youth

development and education. Individually and collectively,

council and committee members can participate in

sensitisation and advocacy, review draft materials and

policies, and develop a comprehensive workplan for

classroom delivery together with plans for monitoring

and evaluation. At the policy level, a well-developed

national policy on sexuality education should be

explicitly linked to education sector plans, as well as to

the national strategic plan and policy framework on HIV

and AIDS. These should clearly promote condentiality

and prohibit sexual harassment and abuse among

school personnel (including teachers) and discrimination

in general (amongst students and teachers).

In order to ensure continuity and consistency and to

minimise opposition to improving sexuality education,discussions about building support and capacity for

school-based sexuality education need to occur at,

and across, all levels. Participants in such discussions

should be provided, as appropriate, with orientation

and training in sexuality and sexual and reproductive

health. This should include values clarication and

desensitisation. Teachers responsible for the delivery of

sexuality education will usually also need desensitisation

and training in the use of active, participatory learning

methods.

3.4 At school level

The overall school context within which sexuality

education is to be delivered is crucially important. In

this regard, two linked factors will make a difference:(1) leadership, and (2) policy guidance. Firstly, school

management is expected to take the lead in motivating

and supporting, as well as creating the right climate in

which to implement sexuality education and address

the needs of young people. From the perspective of

a classroom, instructional leadership requires teachers

to take the lead in how children and young people

experience sexuality education through discovery,

learning and growth. In a climate of uncertainty or

conict, the capacity to lead amongst managers and

teachers can make the difference between successful

programmatic interventions and those that falter.

Secondly, implementing sexuality education within

the framework of a clear set of relevant school-

wide policies or guidelines concerning, for example,

sexual and reproductive health, gender discrimination

(including sexual harassment) and bullying (including

homophobia) has a number of advantages. A policy

framework will:

Provide an institutional framework for the imple-

mentation of sexuality education programmes; Anticipate and address sensitivities concerning

the implementation of sexuality education pro-

grammes;

Set standards on condentiality;

Set standards of appropriate behaviour; and

Protect and support teachers responsible for

delivery of sexuality education and, if appropriate,

protect or increase their status within the school

and community.

It is possible that some of these issues may be well

dened through pre-existing school policies. For

example, most school-based policies on HIV and

AIDS pay specic attention to issues of condentiality,

discrimination and gender inequality. However, in the

absence of pre-existing guidance, a policy on sexuality

education will clarify and strengthen the schools

commitment to:

Curriculum delivery by trained teachers;

Parental involvement;

Procedures for responding to parental concerns;

Supporting pregnant learners to continue with theireducation;


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Making the school a health-promoting environment

(through provision of clean, private, separate toilets

for girls and boys, and other measures);

Action in the case of infringement of policy, for

example, in the case of breach of condentiality,

stigma and discrimination, sexual harassment or

bullying; and Promoting access and links to local sexual and

reproductive health and other services.

Decisions will also need to be made about how to select

teachers to implement sexuality education programmes,

and whether this should be done by aptitude or personal

preference, or whether it should be required of all teachers

delivering a particular subject or set of subjects.

Implementation planning needs to take into consideration

adequate development and provision of resources

(including materials), and needs to reach agreement

on the place of the programme within the broader

curriculum. Furthermore, it should include planning for

pre-service training at teacher training colleges, and in-

service and refresher training for classroom teachers,

to build their comfort and condence, and to develop

their skills in participatory and active learning.

3.5 Parental involvement

Many parents may have strong views and concerns

(sometimes misplaced) about the effects of sexuality

education. The cooperation and support of parents should

be sought from the outset and regularly reinforced. It is

important to emphasise the shared primary concern of

schools and parents with promoting the safety and well-

being of students. Parental concerns can be addressed

through the provision of parallel programmes that orient

them to the content of their childrens learning and that

equip them with skills to communicate more openly

and honestly about sexuality with their children, putting

their fears to rest and supporting the schools efforts in

delivering good quality sexuality education. If parents

themselves are anxious about the appropriateness of

curriculum content or unwilling to engage in what their

children learn through sexuality education programmes,

the chances of personal growth for children and young

people are likely to be limited. However, in the best

possible scenario, teachers and parents work to support

each other in implementing a guided and structured

teaching/learning process.

3.6 Schools as communityresources

Schools can become trusted community centres that

provide necessary links to other resources, such asservices for sexual and reproductive health, substance

abuse, gender-based violence and domestic crisis11.Thislink between the school and community is particularly

important in terms of child protection, since some

groups of children and young people are particularly

vulnerable. These include those who are displaced,

disabled, orphaned, or living with HIV. They need

relevant information and skills to protect themselves,

together with access to community services to help

protect them from violence, exploitation and abuse.


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4. The evidence base for sexuality education

4.1 2008 Review of the impact of sexuality education on sexualbehaviour

This section presents a summary of the ndings of a recent review of the impact of sexuality education on sexual

behaviour. It was commissioned by UNESCO in 2008 as part of the development of these International Guidelines.

The review considered 87 studies from around the world (see Table 2 below); 29 studies were from developing

countries, 47 from the United States and 11 from other developed countries (please refer to Appendix IV for a detailed

description of the criteria for the selection of evaluation studies). All of the programmes were designed to reduce

unintended pregnancy or STIs, including HIV; they were not designed to address the varied needs of young people or

their right to information about many topics. All were curriculum-based programmes, 70 per cent were implemented

in schools and the remainder were implemented in community or clinic settings. Many were very modest, lasting less

than 30 hours or even 15 hours. The review examined the impact of these programmes on those sexual behaviours

that directly affect pregnancy and sexual transmission of HIV and other STIs. It did not review impact on other

behaviours such as health-seeking behaviour, sexual harassment, sexual violence or unsafe abortion.

Table 2. The number of sexuality education programmes with indicated effects

on sexual behaviours

Developing

Countries (N=29)

United States

(N=47)

Other developed

Countries (N=11)

All Countries

(N=87)

Initiation of Sex

Delayed initiation 6 15 2 23 38%

Hadnosignicantimpact 16 17 7 37 62%

Hastened initiation 0 0 0 0 0%

Frequency of Sex

Decreased frequency 4 6 0 10 31%


Increased frequency 0 0 1 1 3%

Number of Sexual Partners

Decreased number 5 11 0 16 44%


Increased number 0 0 0 0 0%

Use of Condoms

Increased use 7 14 2 23 40%


Decreased use 0 0 0 0 0%

Use of Contraception

Increased use 1 4 1 6 40%


Decreased use 0 1 0 1 7%

Sexual Risk-Taking

Reduced risk 1 15 0 16 53%


Increased risk 1 0 0 1 3%


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Limitations and strengths of the review

There were a number of limitations to the studies and,

by implication, to the review. Too few of the studies

were conducted in developing countries. Some

studies suffered from an inadequate description of their

respective programmes. None examined programmesfor gay or lesbian or other young people engaging in

same-sex sexual behaviour. Some studies had only

barely adequate evaluation designs and many were

statistically underpowered. Most did not adjust for

multiple tests of signicance. Few studies measured

impact upon either STI or pregnancy rates and fewer

still measured impact on STI or pregnancy rates with

biological markers. Finally, there were inherent biases

that affect the publication of studies: researchers are

more likely to try to publish articles if positive results

support their theories. Also, programmes and journals

are more likely to accept articles for publication when

results are positive. Fortunately, some of these biases

counteract each other.

Despite these limitations, there is much to be learned

from these studies for several reasons: 1) 87, all with

experimental or quasi-experimental designs, is a large

number of studies; 2) some of the studies employed

very strong research designs and their results were

similar to those with weaker evaluation designs; 3)

when the same programme was studied multiple times,

often the same or similar results were obtained; and 4)the programmes that were effective at changing sexual

behaviour often shared common characteristics.

4.2 Impact on sexualbehaviour

Of sixty studies that measured the impact of sexuality

education programmes upon the initiation of sexual

intercourse, 38 per cent delayed the initiation of sexual

intercourse among either the entire sample or an

important sub-sample, while 62 per cent had no impact.

Notably, none of the programmes hastened the initiation

of sexual intercourse. Similarly, 31 per cent of the

programmes led to a decrease in the frequency of sexual

intercourse (which includes reverting to abstinence), while

66 per cent had no impact and 3 per cent increased

the frequency of sexual intercourse. Finally, 44 per cent

of the programmes decreased the number of sexual

partners, 56 per cent had no impact in this regard, and

none led to an increased number of partners. The smallpercentages of results in the undesired direction are

equal to, or less than, that which would be expected by

chance, given the large number of tests of signicance

that were examined. Also by the same principle, a few of

the positive results were probably the result of chance.

Thus, taken together, these studies provide very

strong evidence that, despite fears to the contrary,programmes that emphasise not having sexual

intercourse as the safest option and that also discuss

condom and contraceptive use do not increase sexual

behaviour. On the contrary:

more than a third delayed the initiation of sexual

intercourse;

about a third decreased the frequency of sexual

intercourse; and

more than a third decreased the number of sexual

partners, either among the entire sample or in

important sub-samples.

4.3 Impact on condom andcontraceptive use

Forty per cent of programmes were found to increase

condom use, while sixty per cent had no impact and none

decreased condom use. Forty per cent of programmes

also increased contraceptive use; 53 per cent had noimpact, and 7 per cent (a single programme) reduced

contraceptive use. Some studies assessed measures

that included both the amount of sexual activity as well

as condom or contraceptive use in the same measure.

For example, some studies measured the frequency of

sexual intercourse without condoms or the number of

sexual partners with whom condoms were not always

used. These measures were grouped and labelled sexual

risk-taking. Fifty-three per cent of the programmes

decreased sexual risk-taking; 43 per cent had no impact

and three per cent were found to increase it.

In summary, these studies demonstrate that more

than a third of the programmes increased condom or

contraceptive use, while more than half reduced sexual

risk-taking, either among entire samples or in important

sub-samples.

The positive results on the three measures of sexual

activity, namely on condom and contraceptive use and

sexual risk-taking, are essentially the same when the

studies are restricted to large studies with rigorous

experimental designs. Thus, the evidence for thepositive impacts upon behaviour is quite strong.


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4.4 Impact on STI, pregnancyand birth rates

Because STI, pregnancy and childbearing occur less

frequently than sexual activity, condom or contraceptiveuse, the distributions of the outcome measures of STI,

pregnancy or childbearing require that considerably

larger samples are needed to measure adequately

the impact of programmes upon STI and pregnancy

rates. Because many studies present results without

having adequate statistical power, these results are not

presented in Table 2.

While a small number of studies did evaluate programmes

that had a signicant reduction in STI and/or pregnancy

rates, a greater number did not. At least two of the

positive results were demonstrated by biological

markers. However, other studies employing biological

markers failed to demonstrate signicant results, even

when they had sufcient statistical power.

4.5 Magnitude and durationof impact

Even the effective programmes did not dramaticallyreduce risky sexual behaviour; their effects were more

modest. The most effective programmes tended to

lower risky sexual behaviour by, very roughly, one-

fourth to one-third.

Some comprehensive programmes had effects

on behaviour that lasted for as long as eight years

afterwards, but most did not measure impact over

such a long time span.

4.6 Breadth of behaviourresults

Comprehensive programmes were effective in changing

behaviour when implemented in school, clinic andcommunity settings and when addressing different

groups of young people: e.g. both males and females,

sexually inexperienced and experienced youth, and

young people at lower and higher risk in disadvantaged

and better-off communities.

Box 3. Mema Kwa Vijana

(Good things for young people)

http://www.memakwavijana.org

A particularly strong and interesting study is that of theMemaKwaVijanaprogramme(MKV)intheUnitedRepublicof

Tanzania. This study evaluated the impact of a multi-component

programme comprised of a strong classroom-based curriculum,

youth-friendly reproductive health services, community-based

condom promotion and distribution for and by peers, together

with a community sensitisation effort to create a supportive

environment for the interventions.

A rigorous randomised trial found that the programme had some

positive effects on reported sexual behaviour. For example,

after a period of eight years the programme reduced the

percentage of males who reported four or more lifetime sexual

partners from 48 per cent to 40 per cent. It also increased the

percentage of females who reported using a condom with acasual sexual partner from 31 per cent to 45 per cent.

However, the programme did not have any impact on HIV,

other STI or pregnancy rates. There are at least three possible

explanations for this. First, study participants reports of

sexual behaviour may have been biased and the programme

may not have actually changed sexual behaviour. Second, the

programme may have changed risk behaviours, but may not

havechangedthespecicbehavioursthathavethegreatest

impact on pregnancy, STIs and HIV. Third, the programme may

not have changed behaviours to such an extent as to make a

difference in rates of pregnancy, STI and HIV.

Whatever the explanation, the study is a caution that even awell-designed, curriculum-based programme implemented in

concert with mutually reinforcing community-based elements

stillmaynothavea signicant impact onpregnancy,STI or

HIV rates.
http://www.memakwavijana.org/http://www.memakwavijana.org/


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4.7 Results of replicationstudies

Results from several replication studies in the United States

are encouraging12

. These studies demonstrate that whenprogrammes found to be effective at changing behaviour

in one study were replicated in similar settings, either by

the same or different researchers, they consistently yielded

positive results. Programmes were less likely to remain

effective when their duration was shortened considerably,

when they omitted activities that focused on increasing

condom use, or when they were designed for and

evaluated in community settings, but were subsequently

implemented in classroom settings.

4.8 Abstinence-onlyprogrammes

In addition to the effects of the sexuality education

programs described above, eleven abstinence-only

programmes, all of which were conducted in the United

States13, met the selection criteria for the review. Six

of the studies were particularly rigorous: employed

experimental designs, measured long-term impact,

and used statistical analyses. Results demonstratedthat the curricula had no effects on initiation of sexual

intercourse, age of initiation of sexual intercourse,

abstinence in the previous twelve months, number

of sexual partners, or condom use during sexual

intercourse.

Studies of the remaining abstinence-only programmes

were methodologically weaker. These employed quasi-

experimental designs with comparison groups that were

not always well-matched. Some had high attrition rates,

weaker statistical analysis or measured programme

impact for shorter periods of time. Of these ve weaker

studies, two reported that the evaluated programme

delayed sexual initiation. The three remaining studies

showed no signicant effect upon sexual behaviour.

Two of these measured programme impact on the

frequency of sexual intercourse among young people

who had previously had sexual intercourse. Both

reported that the programmes reduced the frequency

of sexual intercourse. The single study that measuredprogramme impact upon the number of sexual partners

found that the curriculum resulted in a reduction in the

number of sexual partners among participating young

people. Of the studies with either experimental or

quasi-experimental designs that measured impact on

either condom or other contraceptive use, none found

a signicant effect.

4.9 Speciccurriculum-based

activities

Few studies have measured the impact of specic

activities within curriculum-based programmes. Two

studies considered the impact of particular activities

within larger, more comprehensive HIV prevention

programmes, integrated within multiple courses in

schools. The rst study found that, when young

people observed a debate on whether schoolchildren

should be taught how to use condoms and then wrote

an essay about ways they could protect themselvesfrom HIV, students were subsequently more likely to

use condoms (Duo et al., 2006). The second study

reported that the following all signicantly decreased

the rate of pregnancy among teenage girls to older

men: providing HIV prevalence rates, disaggregated by

age and sex; emphasising the risk of young women

having sexual intercourse with older men (who are more

likely to be HIV-positive); and showing a video about

the danger of having sexual intercourse with older men

(Dupas, 2007). This biological marker was perceived

to be important both in itself and as an indicator of the

amount of unprotected sexual intercourse between

young women and older males.


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4.10 Impact on cognitive factors

Nearly all sexuality education programmes that have

been studied increased knowledge about different

aspects of sexuality and risk of pregnancy or HIV/STIs. This is important, because increasing knowledge is a

primary role of schools. Programmes that were designed

to reduce sexual risk and employed a logic model also

strove to change other factors that affect sexual behaviour.

Those programmes that were effective at either delaying

or reducing sexual activity or increasing condom or

contraceptive use typically focused on:

Knowledge e.g. of sexual issues, HIV, other STIs

and pregnancy, including methods of prevention;

Perceptions of riske.g. of HIV, other STIs and of

pregnancy;

Personal values about sexual intercourse and

abstinence;

Attitudes about condoms and contraception;

Perceptions of peer norms e.g. about sexual

activity, condoms and contraception;

Self-efcacyto refuse sexual intercourse and to

use condoms;

Intention to abstain from sexual intercourse or to

restrict sexual activity or partners;

Communication e.g. with parents or other adults

and potentially with sexual partners.

It should be emphasised that some studies demonstrated

that particular programmes improved these factors. Other

studies have demonstrated that these factors, in turn, have

an impact on adolescent sexual decision-making. Thus,

there is considerable evidence that effective programmes

actually changed behaviour by having an impact on these

factors, which then positively affected young peoples

sexual behaviour.

4.11 Summary of results

Curriculum-based programmes implemented in

schools or communities should be viewed as an

important component that can often (but not

necessarily always) reduce sexual risk behaviour.

However, isolated from broader programmes in

the community, these programmes are sometimes

insufcient to have a signicant impact in terms of

reducing HIV, STI or pregnancy rates.

There is strong evidence that programmes did not

have negative effects: in particular, they did not

hasten or increase sexual behaviour. The studies

also demonstrate that it is possible, with the same

programmes, to delay sexual intercourse and to

increase the use of condoms or other forms of

contraception. In other words, a dual emphasis onabstinence together with use of protection for those

who are sexually active is not confusing to young

people. Rather, it can be both realistic and effective.

Nearly all studies of sexuality education programmes

demonstrate increased knowledge and about two-

thirds of them demonstrate positive results on

behaviour among either the entire sample or an

important sub-sample.

More than one-fourth of the studies improved

two or more sexual behaviours among young

people. Encouragingly, these studies with positive

behavioural results include studies with strong

research designs and replication studies with

consistent results.

Comparative analysis of effective and ineffective

programmes provides strong evidence that

programmes that incorporate key recommendations

can be effective at changing the behaviours that

put young people at risk of STIs and pregnancy.

Even if sexuality education programmes improve

knowledge, skills and intentions to avoid sexual

risk or to use clinic services, reducing their risk may

be challenging to young people if social norms do

not support risk reduction or clinic services are not

available.

The sexuality education programmes studied had

one big gap in common: none of them appeared

to focus on the behaviours that cause by far the

most HIV infections among adolescents in large

parts of the world (i.e. Europe, Latin America and

the Caribbean and Asia). Those behaviours are

unsafe injecting drug use, unsafe sexual activity in

the context of sex work and unprotected (mainly

anal) sexual intercourse between men.


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5. Characteristicsof effective

programmes

This section sets out the common characteristics

of evaluated sexuality education programmes that

have been found to be effective in terms of increasing

knowledge, clarifying values and attitudes, and increasing

skills and impacting upon behaviour14 (see Tables 3a and

3b). These characteristics build upon those identied

and veried through independent review15.

1. Implement programmes in schools and other

youth-oriented organizations that reach large

numbers of young people.

Programmes have been found to be effective in school,

clinic and community settings. However, a majority of

the programmes that had long-term positive effects

on behaviour have been implemented in schools, or

at least included an important curriculum component

that was implemented in schools. Moreover, in many

places, schools are the easiest place to reach largenumbers of young people, especially younger children

who are more likely to be in school.

2. Implement programmes that include at least

twelve or more sessions.

In order to address the rights of young people to

information about sexuality, multiple topics need to be

covered. In order to reduce sexual risk-taking among

young people, both risk and protective factors that

affect decision-making need to be addressed. Both of

these approaches take time: nearly all the programmes

in schools found to have a positive effect upon long-

term behaviour have included 12 or more sessions,

and sometimes 30 or more sessions, that last roughly

50 minutes or so.

3. Include sequential sessions over several years.

To maximise learning, different topics need to be

covered in an age-appropriate manner over severalyears. When giving young people clear messages

about behaviour, it is also important to reinforce those

messages over time. Most of the programmes found

to have enduring behavioural effects at two or more

years follow-up have either involved the provision of

sequential sessions over the course of two or three

years, or else they are programmes in which most

sessions have been provided during the rst year andfollowed up with booster sessions delivered months,

or even years, later. This enables more sessions to be

provided than might otherwise have been possible.

It also makes it possible to reinforce important

concepts over the course of several years. A few of

these programmes have also implemented school-

or community-wide activities over subsequent years.

Thus, students could be exposed to the curriculum

within the classroom for two or three years and then

their learning could be reinforced through school or

community-wide components in subsequent years.

4. Cover topics in a logical sequence.

Topics should be taught in a logical sequence. Many

effective curricula focus rst upon strengthening

motivation to avoid STI/HIV infection and pregnancy

by emphasising susceptibility to and severity of these,

before going on to address the specic knowledge,

attitudes and skills required to avoid them.

5. Employ educationally sound methods that

actively involve participants and assist them to

personalise information.

A broad range of participatory teaching methods have

been used in the implementation of effective curricula.

Typically these promote the active involvement of

students in a task or activity, conducted in the classroom

or community, followed by a period of discussion or

reection in order to draw out specic learning. Methods

need to be matched to specic learning objectives.

6. Employ activities, instructional methods and

behavioural messages that are appropriate to

young peoples culture, developmental age and

sexual experience.

To be maximally effective, curricula must be consistent

with the community, culture, age and sexual experience of

students. Some effective curricula have been designed for

specic racial or ethnic groups. These programmes draw

attention to the high rates of HIV, other STIs or pregnancyamong those groups and emphasise the need for young


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people to avoid unprotected sexual activity as a way of

being responsible for themselves and their communities.

Other curricula have been designed specically for young

women, emphasising that young women can be powerful

and in control of sexual situations (i.e. by not having sexual

intercourse when they do not want to and always using a

condom if they have sexual intercourse). Given the muchhigher rates of HIV infection among men-who-have-sex-

with-men, efforts are underway in some countries to

develop specic curricula for young men-who-have-sex-

with-men16.

Teaching methods used in effective curricula are

consistent with the developmental age of the students.

Activities for younger students typically included more

basic information, less advanced cognitive tasks, and

less complex activities.

7. Include homework assignments to increase

communication with parents or other adults.

The most effective way to increase parent-to-child

communication about sexuality is to provide student

homework assignments to discuss selected topics with

parents or other trusted adults. Such assignments can

begin with relatively safe topics and progress towards

more sensitive ones.

Some programmes prepare parents by providing themwith relevant information or else help them acquire

skills to enable them to talk more comfortably with their

own children about sexual matters. In communities

where parents may not be adequately informed about

important reproductive health issues, a concentrated

programme for parents may also be needed.

8. Address gender issues and sensitivities in both

the content and teaching approach.

Gender affects the experience of sexuality, sexual

behaviour and reproductive health. Gender discrimination

is common and young women often have less power

or control in their relationships, making them more

vulnerable, in some settings, to abuse and exploitation

by older men. Men may also feel pressure from their

peers to full male stereotypes.

In order to be effective at reducing sexual risk behaviour,

effective curricula need to examine and address these

gender inequalities and stereotypes. For example, they

need to discuss the special circumstances faced by

young women (or young men) and generate effective

methods of avoiding unwanted or unprotected sexual

intercourse in those situations. Such activities might

also contribute in a small way to the reduction of

entrenched gender inequality and stereotyping.

Important contextual factorsto consider

In addition to these characteristics of effective pro-

grammes, the following key contextual factors also

need to be addressed, even if a rigorous evidence base

in support of such efforts is not yet available.

9. Ensure that a supportive policy environment is

in place.

The sensitive and sometimes controversial nature of

sexuality education makes it important that supportive

policies are in place, demonstrating that the delivery

and curricula of sexuality education are a matter of

institutional policy rather than the personal choice of an

individual teacher. Such policies are usually developed

primarily by the national ministries of education or

health, but in some settings they need to be reinforced

or sanctioned at state or local level.

Programmes are more likely to run smoothly when they

are implemented within appropriate, overarching national

development frameworks, together with relevant policies

on health (e.g. HIV and AIDS) and social issues (e.g.

discrimination or exclusion).

These policies are best developed in consultation

with key stakeholders, such as teachers unions, faith

communities, NGOs and other representatives of civil

society, including young people. For example, robust

policies in support of sexual well-being such as zero

tolerance of sexual harassment, abuse, violence and

discrimination give clear messages to staff and students

alike. Where laws or policies exist that could preclude

the implementation of effective programmes, advocacy

may need to be undertaken in order to pave the way for

the introduction of sexuality education programmes.

These programmes may need to undergo ofcial

review and approval, teacher accreditation, grade-level

sequencing, testing and other requirements in order to

comply with existing policy and practice.


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10. Select capable and motivated educators to

implement the curriculum.

The qualities of the educators can have a huge

impact on the effectiveness of the curriculum. Those

who deliver curricula should be selected through

a transparent process that identies relevant anddesirable characteristics. These include: an interest in

teaching the curriculum; personal comfort discussing

sexuality; ability to communicate with students; and

skill in the use of participatory learning methodologies.

If they lack knowledge about the topic, that knowledge

can be provided by training (see next characteristic).

If it is mostly men who are likely to be selected as

educators, then strategies can be implemented to

recruit more women.

Educators may be the regular classroom teachers

(especially health education teachers) or specially

trained teachers who only teach sexuality education

and move from classroom to classroom covering all of

the relevant classes in the schools. The advantages of

general classroom teachers include the following: they

are part of the school structure; they may be known

and trusted by the community; they have already

established relationships with learners; and they can

integrate sexuality education messages into different

subjects. The advantages of using specialist sexuality

education educators include: they can be specially

trained to cover this sensitive topic and to implementparticipatory activities; they can be provided with

regularly updated information; and they can be linked

to community-based reproductive health services.

Studies have demonstrated that programmes can be

effectively delivered by both groups of educators.

Debate continues regarding the relative potential

efcacy of peer-led versus adult-led delivery of sexuality

education curricula. There is stronger evidence that

adult-led (as compared to peer-led) programmes

demonstrate positive effects on behaviour. However, this

reects the larger number of studies that have focused

on adult-led programmes. Three randomised trials

and a formal meta-analysis comparing the respective

effectiveness of adult- and peer-led programmes have

been inconclusive. None have found strong evidence

that adult-led programmes are more or less effective

than peer-led programmes.

11. Provide quality training to educators.

For teachers, delivering sexuality education often

involves both new concepts and new learning methods

and thus specialised training is important. This training

should have clear goals and objectives, should teach

and provide practice in participatory learning methods,should provide a good balance between learning content

and skills, should be based on the curriculum that is to

be implemented, and should provide opportunities to

rehearse key lessons in the curriculum. All of this can

increase the condence and capability of the educators.

The training should help educators distinguish between

their personal values and the health needs of the

learners. It should encourage educators to teach the

curriculum completely and with delity, not selectively.

It should address challenges that will occur in some

commun

Documents

Unesco International Guidelines on Sexuality Education 183281e